Barriers to new innovation in the UK’s NHS – and how to overcome them – Part 2

In Part 1 of this blog I discussed how companies need to build innovative products together with clinicians, in order to work out what helps them and their patients, rather than companies making assumptions about medical needs which may not actually be valid, which can create barriers to innovation.

Another barrier to innovation in the NHS which was raised in the Nuffield Trust’s report (link) was that, “Products are sought which lead to short-term savings, rather than transforming care pathways leading to more efficient services”.

Stories of NHS managers introducing cheaper versions of products which turn out to be more expensive overall are rife: examination gloves which split, and two or three are wasted before a useful pair is found. Paper towels which don’t come out of the dispensers properly, and end up being wasted on the floor. But far more worryingly – spending money on areas which do not improve care, and can actually hinder it.

Last year, Jeremy Hunt announced that he would be putting millions of pounds of investment into more CTG machines, despite there being zero evidence that continuous monitoring is safer than intermittent monitoring. Imagine instead if that money had been allocated to increasing midwife numbers to implement Continuity of Carer? Unlike CTG machines, Continuity of Carer has been shown to reduce stillbirth, as well as costs to the NHS such as caesarean births.

Far cheaper investments, such as birth pools, also leads to significant cost savings. Labouring in water increases the rate of spontaneous vaginal births, reduces the need for instrumental delivery, reduces the numbers of 3rd and 4th degree tears, lowers the chance of a woman wanting opiate pain relief or an epidural, and increases women’s positive experiences of birth which might lead to lower levels of PND. (1)  ALL of these mean that the NHS spends less money on fixing the consequences of these interventions, as well as the cost of the intervention itself.

Let’s see the NHS looking at the wider picture with every new innovation or investment. We call upon commissioners to look past the cost of installing new equipment which supports women to birth more easily, and instead see the full spectrum of ways that an investment in a birth pool, or other normal birth promoting products, can save the cash-strapped NHS money, while leading to better outcomes for women and their babies.

References:

(1) Evidence Based Birth: Waterbirth

 

 

Barriers to new innovation in the UK’s NHS – and how to overcome them – Part 1

While many barriers to new innovation in the NHS are well documented, the Nuffield Trust has released a report which looks at areas which have received less focus, and yet which are key to change.

Two of the main barriers listed were:

  • Lack of clinician time to identify problems, and to work with companies to provide solutions
  • Products are sought which lead to short-term savings, rather than transforming care pathways leading to more efficient services – I will discuss this in the next blog.

Lack of clinician time to identify problems and to help to work with innovators to find solutions is a problem which is certainly not limited to the NHS. All industries provide insufficient resources to allow staff the time, space and training to sit back and look at where problems are, and to work on solutions to those problems. In the NHS this leads to solutions being offered by companies which have not always been designed together with the clinicians, or the users of those products.

Nurses - starched caps
Two nurses wearing old fashioned starched caps

Sometimes a problem is identified and the solution put forward does resolve a problem, but causes another because the designer doesn’t work within the care setting. Although this isn’t a clinical product example, it underlines the problem well: In the 80s, some female nurses still wore starched fabric caps (male nurses were not required to as the fashion followed nurses originally being primarily nuns, and then the Victorian era of women needing a head covering). I well remember my own mother spending hours over the ironing board spraying starch onto her nursing caps. One day she told us that they were moving from the fabric cap to a disposable cardboard version (at a daily cost of 2p per cap to the NHS). Rather than working out whether the cap was a relic from the past which interfered with clinical care and should be removed from the uniform, the solution to the complaints of female nurses that they spent hours getting their caps stiff and sturdy was resolved with an expensive and pointless alternative product.

Aquabirths heart-shaped birth pool
Aquabirths’ Heart-Shaped Birth Pool

Aquabirths is lucky to have worked with midwives right from the start of the design of all of our birth pools. Pictured is our heart shaped birth pool  which was designed together with midwives from Leeds, Yorkshire, UK. They requested featured such as:

  • A freestanding pool to enable midwives and birth companions to be able to easily support the birthing woman from any side of the birth pool.
  • A larger birth pool to offer comfort and support to even the tallest women.
  • Smoothed edges to ensure comfort for women and midwives leaning over the edge of the birth pool, often for long periods of time.
  • A single surface birth pool to ensure that it can easily and thoroughly be cleaned.

Aquabirths continues to work with midwives and birthing women to ensure that our birth pools are  designed just how the users of our pools need them to be, and we hope to see more of a trend across the NHS to working this way with product manufacturers.

Oldham Birth Centre: Nurturing Families

Oldham Birth Centre – A Place to Want to Labour!

Aquabirths birth poolOldham, in Greater Manchester, UK, has created the most stunning, supportive and effective birth centre which is family-centred and woman friendly. Designed to nurture women and birth, creating a safe, positive and caring space for the whole family – including other children, who can be present at the birth of their sibling.

Designed to support the physiology of birth from the ground up, the Birth Centre rooms do not centre around an obstetric bed. Instead, they feature slings, balls, mats, Softbirth couches, adjustable lighting and the stunning Aquabirths birth pool, with a large family bed available for parents and baby to rest in after their little one is born.

The Oldham Birth Centre’s philosophy of care is key to the success of this midwife-led maternity unit. Midwives are trained in hypnobirthing techniques, aromatherapy, acupuncture and using water to support positive, safe, physiological birth. Minimising adrenaline is key to maximising oxytocin, and maximising oxytocin is key to birth progressing well, so the whole room is designed to be calm and to help everyone to relax. An aromatherapy diffuser by the door greets the birthing family as they arrive, and the scents in the air, the dimmed lights offset by coloured bubble lamps and the Aquabirths birth pool gives a sense of walking into a spa.

Oldham Birth Centre Wall Painting
Oldham Birth Centre Wall Painting

Midwives describe seeing women sitting in a chair and looking around, and visibly relaxing. A kitchen is available for all to use, so birth partners can help themselves to drinks, and they can make their own snacks. Midwives make it quite clear that this space is for them to use, which is an important part of helping everyone to relax and continue to reduce any adrenaline levels.

The Oldham Birth Centre is not an extension of the labour ward, but instead is designed as a birth centre for the families of the city. While there are strict criteria for straightforward access to the unit, if a woman wants to birth there she can attend a Birth Options Clinic where their choice of place of birth is discussed, and the woman will be supported by the midwives.

The unit itself is nothing without its midwives, and the midwives at Oldham are hand picked for their inbuilt nurturing nature – not a trait which can be taught. Diane watches the student midwives who show an interest in physiological birth and support women’s choices. Those who wish to become part of the community/birth centre team are encouraged to apply.

Oldham Birth Centre is not unique, but it is unusual and it is beautiful. The women and families of Greater Manchester are extremely lucky to have this wonderful facility with its fabulous midwives.
The unit has a video on You Tube which showcases the birth pool and other facilities: https://www.youtube.com/watch?v=2wOHqJfLhGg

Better Births in Powys – Supporting Women, Improving Care

Powys delivering better births
Ruth Weston of Aquabirths in the new Aquabirths birth pool installed in one of Powys’ birth centres.

Powys: Supporting women and supporting Better Births.

In the heart of Wales, in one of the most rural areas of the United Kingdom, lies the beautiful county of Powys. In this stunning region the recommendations of The Birthplace Study and Better Births are being wholeheartedly implemented. In extraordinary contrast to some areas of the UK, Powys has determined to ensure that Midwife Led Units are recommended as the optimal birth place for healthy women and babies, provided they are happy to birth there – supporting women in their decisions and supporting Better Births.  20% of women give birth in a midwife led unit in this area, compared to 14% for the rest of the UK.

Powys has 6 midwife led units across the county, limiting the distance that women need to travel in labour, increasing safety for women and babies and reducing the stress on families at a time where the birthing woman needs to be able to focus on her job at hand.  In addition, Newtown, one of Powys’ towns with a birth centre, has recently celebrated  the huge achievement of obtaining funding to run sonographer services local to where women are, reducing the travelling distances for women by 3000 miles a year!

Newtown has also used its funding to add in a permanent Aquabirths birth pool, and a double bed so that new parents can snuggle up together with their baby after the birth, rather than being separated at one of the most profound times of their lives.

Well done Powys – you are an inspiration!

Guest blog by Emma Ashworth

Out with the Obstetric Beds and In with the SoftBirth Birth Couches!

SoftBirth Logo

Softbirth Birth Couches – How Trusts are using them in Midwifery Led Units and Obstetric Units

Warrington and Halton NHS Trust have thrown out some of the traditional mechanical beds in both the Midwifery Led Unit (MLU) AND the obstetric unit and replaced them with Softbirth Birth Couches! Knowing that women have the best chance of a positive birth in an environment which best supports a birthing woman’s biological need to move and change position, MLU Manager Carys Hammond, Head of Midwifery Dr Tracey Cooper and their teams have created a hugely positive change in their Trust.SoftBirth Birth Couches in obstetric units and midwifery led units

Carys said, “We realised that not every woman needs the mechanical obstetric beds. We wanted to change the rooms, make them physically different, so that midwives would offer the birthing couch room to women. They use pieces of the couch to adapt to different birthing positions and be upright and mobile. It totally changes the ambiance of the room. It’s not right for everyone, and women’s needs are evaluated individually in partnership between the woman and the staff, but the birth environment is really important. Midwives are excited about them!”

Carys reported that the Trust was supportive of the changes. Senior management helped the midwifery team to work through the infection control and governance procedures and getting their support was key to this project.

The Trust midwives are ensuring that women are aware of the options of the birth couch in both the obstetric unit and the MLU. This is done in a variety of ways, including their monthly “Maternity Voices” meetings, their Facebook page (link: https://www.facebook.com/WarringtonAndHaltonHospitalsNhsFoundationTrust/) and on the tours around the wards which are offered to pregnant parents.

“These changes are evidence based,” said Carys, “and it’s what women are asking for. Remember who is important – the women.”

To  find more about introducing SoftBirth birth couches into obstetric units or midwifery led units, please get in touch.

 

 

 

 

Waterbirth : Part of a World Movement

Revisiting WaterbirthBarbara Harper, founder/director of Waterbirth International reviews the second edition of Dianne Garland’s textbook ‘Revisiting Waterbirth: An Attitude to Care’ in the context of waterbirth practice around the world.

It is no secret that water is healing and that the use of water is an effective medium to facilitate changes in actual brain wiring. It is with excitement and great pleasure that I welcome the publication of the second edition of Revisiting Waterbirth: An Attitude to Care. Dianne Garland has continued to provide waterbirth education and training not only throughout the UK, but around the world. Our mutual passion brought us together for conferences, workshops and presentations many times. It has been my privilege to work closely with Dianne as a teaching partner in China, Spain, the Czech Republic, Israel, India and the United States. Her excitement about demystifying waterbirth is contagious, and the reader, whether midwife, doctor or mother, will experience that enthusiasm within the pages of this book.

There has never been a time in our combined history when the message and knowledge within Revisiting Waterbirth: An Attitude to Care has been more necessary. The misinformation surrounding waterbirth that Dianne and I have witnessed in different parts of the world is sometimes distressing and occasionally humorous. This book gives every practitioner an effective, informative guide to start a waterbirth practice and integrate that practice into any clinical setting. It also provides concrete examples and stories from those with whom Dianne and I have worked. The inclusion of detailed stories from practitioners and parents is a wonderful supplement to the new edition of Revisiting Waterbirth.

The use of water for labour and birth has increased exponentially since Dianne and I first started writing letters to one another in 1989. When we finally met in person 26 years ago in Kobe, Japan, at the International Confederation of Midwives conference, we excitedly shared documentation of the efficacy and safety of waterbirth. The demand for accurate, useful information and descriptions of experiences has also increased. When we first started our collaboration, waterbirth was referred to as a fad or a trend that would soon be gone. Women seeking the ease and comfort of water will continue to increase in every part of the world. Waterbirth is part of a world movement that seeks a more humane and gentler approach to childbearing.

The use of warm water immersion has long been seen as an aid for labour, making it easier for the mother to enter into and remain in a state of hormonal bliss. Today, there are well-designed studies that prove the efficacy of water for labour and the safety of water for the birth of the baby. Dianne’s experience as a hands-on midwife attending waterbirths, as well as her design and documentation of research, makes her the perfect person to lay the foundation of education for those who want to incorporate the use of water into maternity care settings. This book is also a guide for those who have already started waterbirth practice to improve their experience.

The message in this book is simple, straightforward and very hopeful. It is hopeful in the sense that more and more women are asking how to make labour less about ‘enduring the pain’ and more about creating a good, healthy and loving experience of birth for the baby. Women understand that creating a new human being is one of the most important jobs on the planet. The providers who serve those women need the encouragement that this book offers to step out of the routine medical care and become open to the possibilities that water can, indeed, change the course of a labour and should be utilized as a valuable tool for almost all women. The attitude with which professionals view a woman’s ability to give birth can either enhance or detract from her experience.

In 2014, the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatricians (AAP) launched a campaign to put doubt about the usefulness of waterbirth into the minds of nurses, doctors, midwives and the public. Some US hospitals paid attention to the published and widely distributed ACOG opinion paper and halted their successful and incident-free waterbirth programs. Dianne and I travelled together to hospitals in Cleveland, Ohio, and Minneapolis, Minnesota, shortly after the article was published, to educate hospital staff and help reinstate waterbirth policies in these facilities. We were welcomed in these places and our efforts were rewarded when the practices were put back into place.

It is my sincere hope and desire that practitioners throughout the world are guided by the message in Revisiting Waterbirth: An Attitude to Care and start implementing protocols in more hospitals. All women should be offered the choice and opportunity to labor in water and birth their babies with the ease, safety and pleasure that water so beautifully provides. I also hope that our tandem careers continue to bring this message to every corner of the globe. As founder and director of Waterbirth International, I have relied on Dianne Garland to provide a multitude of research and documentation from the UK and have used this book in its earlier editions as a teaching tool and recommended reading for nurses, midwives and doctors.

Barbara Harper, RN, CLD, CCCE, CKC, Midwife
Founder/Director of Waterbirth International

I’m Group B Strep (GBS) Positive. Can I have a Waterbirth?

GBS testing is not routinely offered to women in the UK.  This is because it is considered that the high rate of carriage compared to the low rate of infection means that the harm done to women and babies in offering antibiotics to every woman who is carrying GBS would outweigh the benefits.

However, some women do end up being tested for one reason or another, and those who find that they are carrying GBS are often then denied access to water during their birth (unless they’re at home, in which case it’s always the woman’s own decision). Aquabirths asks, “Is this a reasonable position for trusts to take?”.

Many trusts are open to women birthing in water and some are not, and within trusts some midwives or obstetricians will deny women access to the trust’s pools, and others will be completely happy to support women who want to use a pool for their birth. What’s going on?

There is limited data on the impact of waterbirth on how many babies born to women who are carrying GBS, but what data there is shows either a reduction in the numbers of babies born underwater who are infected with GBS, or no statistical difference, but with a trend towards a reduction in affected babies who are born underwater. This is despite the fact that the water in a pool birth could have high levels of GBS in it, and therefore the theory is that the water is essentially washing the baby and mother, providing some increased level of protection compared to babies born on dry land. (1)

An article by JS Cohain (2) states that infection with GBS was 1/4432 in babies born underwater v 1/1450 in babies born on land – that’s three times as many babies becoming infected with GBS when they’re born on land than babies born underwater! The article discusses the reasons for this, including considering whether it might be “a massively successful international campaign has covered up the reporting of all deaths and disease from GBS after waterbirths.” There’s nothing like covering all bases!

Even though the evidence on GBS and waterbirth is limited and more studies are needed, if the trend was the other way – that more babies seemed to be infected with GBS when born in water – there would be no doubt that there would be a huge push to try to ban birth in water! Given that the opposite is true, and the best data that we have shows a trend towards fewer babies being infected with GBS when they’re born under water, opening up water birth to women who have found that they’re carrying GBS is something that every birth centre and obstetric unit should support.

Article by Emma Ashworth.

Many thanks to Dianne Garland for her help with this article.

References:

(1) Springer Link, “Water birth: is the water an additional reservoir for group B streptococcus?” 

(2) Pubmed, “Waterbirth and GBS”

Further Reading:

AIMS GBS book, “Group B Strep Explained”

RCOG “Group B Strep and Waterbirth”

Practicing Midwife for the GBSS, “Waterbirth for women with GBS: a pipe dream?”

Dianne Garland’s book, “Revisiting Waterbirth” is due out in April or May 2017

Things to consider before buying and installing a birthing pool

Things you need to consider when installing a birthing pool – a Midwife’s guide.

 

As the demand for active birth – and water births in particular – increases, more and more trusts and birthing units are installing birthing pools. Here, David Weston, owner of Aquabirths in West Yorkshire shares his expertise and experience and gives guidance on “where to start”.

 

As with many things in midwifery, you have to start with the plumbing.  Is there already a bath in the room where you plan to put your pool?  Or at least a sink?  If the plumbing is in place to begin with, it makes life a lot easier and the job a lot cheaper.  One critical thing is the height of the existing waste water pipe. 

 

Ideally, the waste water will leave the room either at, or very close to, floor level so that pipe-work from plughole to waste drain is at a steep enough gradient to enable the water to empty quickly.  A valve and a trap need to be fitted in under the bath and it’s a case of getting them in before you run out of height. If the waste pipe is a few inches up the wall, then the bath will probably need to be raised, which can add to the overall cost of the build.

 

Space. When putting a pool into a birthing room, you might also want to consider what else you want in the room.  Other room uses may impinge on the bath – for example, plug sockets for CD-players need to be at least 3m from the bath. It’s always a good idea to make contact with an experienced Birth Pool specialist very early in the process. Any company worth their salt will be willing to chat through your options with you, or be prepared to visit you, even before you have engaged an architect or project manager.

 

I have seen rooms with birthing pools left unused or – worse still – used as storage rooms! Allowing time to properly consider how best to equip the room with other equipment can avoid this. If you want a bed in the room with the birth pool, will you want to be able to move the bed in and out also? Will there be enough room to do so. You don’t want to find yourself in a position of not being able to offer the birth pool to women who want it because someone rammed it with a bed and the estates office have told you it can’t be used.   

 

Colours and features.  Gone are the days of “it comes in white…or white” A birthing bath can be any colour and any shape you want and many of the baths we have installed have been adapted to suit the needs of individual midwifery teams. If you have a “dream” birthing pool in mind, don’t be afraid to ask. Modern moulding techniques mean that bespoke baths are much more affordable than they were ten years ago.

 

When it comes to taps, choice can be a little more limited because of the various regulations that apply to hospitals. Any good birth pool company will know their way round these regulations and should still be able to offer you a number of alternatives. It is probable that this is something that can be sorted by the hospital’s Estates Department.  You can also request additional features and modifications such as LED lights inside the bath, a choice on the position of the waste outlet and even the addition of an anti-bacterial gel coating.

 

Make it a Team Effort Involve the Estates Department as early as is possible / helpful to you. They may be able to help with much of the above and undertake some of the works to make your budget go as far as possible.  We do offer an installation service for our pools so you can be sure it is fitted correctly.  However, budgets are often stretched and it should be possible for the hospital’s own Estates Department to fit the bath.  Make sure your pool comes with instructions and telephone support from the birth pool provider. 

 

If you’re not sure, ask. A birth pool may be one of your biggest investments of the year, so don’t be afraid to ask questions throughout the process. Once the bath is in, it’s sometimes too late to make changes so keep the channels of communication open throughout the design, build and installation process.  A good birth pool company will have time to talk through your options and be willing to answer any questions you have. It’s a good idea to have clarification on points you are unsure of in writing to avoid any confusion or surprises later down the line. If you discuss something with your birth pool provider on the phone, drop them a quick email afterwards to confirm what you agreed. Don’t assume that because you know exactly what you want, they do too – they’ll only know if you tell them.

 

And finally – once your pool is installed, make a bit of noise about it. Be sure to let the local press know about your fabulous new facilities (your birth pool company may be able to help you with this) and invite local stakeholders, community midwives, doulas, GPs, practice nurses and mums to be to come and take a tour of your new birthing room. You wouldn’t buy a new pair of shoes and never wear them, likewise don’t commission a pool and forget to show it off – that way it will get used more frequently, you will get your money’s worth and you will see an increase in the number of mums enjoying your new birthing pool.”

 

 

 

 

Chic-looking Compact Birth Baths

Dunoon compact birth pool

The Dunoon model compact birth bath installed at Royal University Hospital, Bath as part of their refurbishments, which were envisioned and overseen by SR Architects.  The Dunoon model is designed to keep all the room of a birth bath for the mum-to-be but to be efficient in its use of space.  If you have small birth room or space is tight, then the Dunoon birthing pool is ideal.  And with a price tag well under £3000, it is also suitable for hospitals that need to fit out several birthpool rooms.  As with all Aquabirths baths, this bath can be customised and is flexible in its design – the hatch can go either side, it can be fitted side-on or end on.  And, as with all our baths, it is a one-piece bath with a single-surface for strength and superior hygiene control.

Proper Installation of Birthing Pools and False Economies.

I doubt if there is a maternity unit in the UK that isn’t strapped for funds.  Savings always need to be found!  But please don’t scrimp on the installation of the birthing bath – this is a job for a qualified plumber and not a general fitter.   This is not a way of pushing our installation service but simply because we’ve just had to tidy up a mess left by a contractor who didn’t install the bath properly.

It is very important that the bath you have bought, paid to be delivered and installed is put in properly to avoid extra costs and problems down the line.  Make sure Estates or someone ensures the contractor follows the instructions.  If you have queries, ring us.  You could have a site visit before hand so that we can discuss installation; you can also  book for our plumber to be present at installation to offer guidance, at the very least, you could arrange for him to be present to give phone support.  The cost of a site visit (which is only for mileage and time) is discounted from the purchase price (up to a maximum of £200) in any case.

We understand that hospitals will want to make saving where they can but, as we know with a local hospital, the installer put the bath in wrongly and with no consideration of the midwives who will have to use it.  This has caused extra expense, hassle and time-wastage trying to sort it.  Othertimes, the incorrect trap has been used so that Infection Control are unhappy.